1300 265 666

Direct Access Endoscopy

 Complete the below online form to refer your patient for a direct access endoscopy. 

 Our staff will contact the patient within 2 days to arrange their endoscopy.

Please contact our staff on 1300 265 666 if your patient needs urgent endoscopy arrangement. 

    * mandatory fields

    PATIENT DETAILS

    Does patient meet criteria being less than 70 years of age of reasonable health (without kidney or heart failure)?*

    Patient’s Given Name *

    Patient’s Last Name *

    Patient’s Date of Birth (dd/mm/yyyy)*

    Patient’s Telephone (Mobile)*

    Patient’s Email Address *

    Patient’s Residential Address *

    Does patient have Medicare?*

    Patient’s Medicare Number (if applicable)

    Medicare Reference Number (the number in front of your name) (if applicable)

    Does patient have private health insurance?*

    Patient’s Private Health Insurer (if applicable)

    Patient’s Private Health Insurance Membership Number (if applicable)

    Is the patient taking blood thinners?

    Is the patient taking diabetic medications?

    Is the patient taking weight loss medications?

    Does the patient have a coronary stent or valve replacement?

    REFERRING DOCTOR’S DETAILS

    Referring Doctor’s first and last name

    Referring Doctor’s phone number or practice details

    Referring Doctor’s fax number, email or HealthLink EDI

    Referring Doctor’s Provider Number

    PROCEDURE DETAILS

    What is the reason for having an endoscopy procedure?*

    Procedure required*

    Please add any additional comments

    * Yes, patient consents to being contacted.



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